THE WORLD BANK

February 2013

NUTRITION in the POST-2015 DEVELOPMENT AGENDA REPORT OF AN EXPERT CONSULTATION SUMMARY AND CONCLUSIONS

Poor nutrition impairs health and human capital development, with significant consequences to economic growth and development: Reducing malnutrition in all its forms will contribute to eliminating preventable maternal and child deaths and to building smart, strong and resilient individuals, families, communities, and populations. This unfinished agenda requires greater focus and attention in the successor framework to the MDGs.

Positioning nutrition in the post-2015 framework: There are several ways that nutrition could be addressed in the post-2015 framework. There was support for a single nutrition goal, leveraging the UN Secretary General’s Zero Hunger Challenge, with its aspirational ‘0 stunting’ goal and establishment of achievable nutrition targets based on lessons from the 2015 MDGs. Thoughtful incorporation of key nutrition indicators into multiple development goals, including health, poverty reduction, education, water and sanitation, agriculture, and governance is a powerful complementary approach to galvanizing action to reach the most vulnerable. This approach recognizes the foundational role that nutrition plays in achieving lasting progress in these other sectors as well as the contribution of these sectors to improved nutrition. Priority nutrition indicators: Among the indicators discussed, childhood stunting was given highest priority, based on its power to capture inequity and chronic conditions of poor health, diet and caring practices during the crucial 1000 days from pregnancy through age 2 of a child’s life. However, participants felt that a focus on stunting alone would be insufficient and that other World Health Assembly-endorsed indicators and targets should be incorporated. Given global trends, future tracking of child overweight was strongly recommended. It is now recognized that we do not live in two worlds, the wealthy suffering from overweight and the poor from undernutrition. Today, it is the same households, families, and at times, the same individuals who are simultaneously stunted, overweight and deficient in key micronutrients.

Urgent need for systems and tools for data collection: Future attention must be paid to systems and tools for gathering better data, particularly on micronutrients and diet quality, important for health and development throughout the lifecycle. Routinely collected nutrition indicators are needed to drive commitment and accountability for achieving our goals.

WORLD HEALTH ASSEMBLY-ENDORSED GLOBAL NUTRITION TARGETS FOR 2025

40% reduction of the global number of children < 5 years who are stunted

50% reduction of anemia in women of reproductive age

30% reduction of low birth weight

No increase in childhood overweight

Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%

Reduce and maintain childhood wasting to less than 5%

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Nutrition in the Post-2015 Development Agenda EXPERT CONSULTATION | February 2013

Introduction

The World Bank and the Bill & Melinda Gates Foundation co-hosted a meeting on February 20, 2013 in Washington, D.C. of nutrition, policy, and advocacy experts from the research, development, and civil society communities to advance the dialogue on nutrition in the post-2015 development agenda and to recommend next steps to incorporate select nutrition indicators/targets in the post-2015 discussions. Collaborating agencies for the meeting included Bread for the World, The 1000 Days Partnership, the Canadian International Development Agency (CIDA) and the International Food Policy Research Institute (IFPRI). This expert consultation reviewed the rationale and success of the current nutrition MDG structure and the priority nutrition challenges for the next 15 years. Participants also discussed the pros and cons of potential nutrition indicators and targets that would best capture and respond to these challenges. This report summarizes the key messages that emerged from this consultation and articulates broadly held opinions about what and how to position nutrition in ongoing institutional and high-level dialogue and engagement with the post-2015 consultation process through 20131.

Lessons learned from the Millennium Development Goals (MDGs)

In the current MDG framework, nutrition is featured as an implicit target under the poverty MDG1, with both positive and negative consequences. The incorporation of a nutrition target under the poverty goal likely wielded some clout given its link with hunger, which received increasing attention due to rising and volatile food prices and the triple threat of the food, fuel, and financial crises in 2007-2008. However, despite the potential benefits of bundling the underweight and hunger targets, it was acknowledged that nutrition did not receive the same level of attention as hunger and poverty, and momentum was lost when it seemed clear that the poverty target would be achieved.

1 This is not a peer reviewed publication. Any opinions stated

herein do not necessarily reflect the policies or opinions of the

participating organizations.

Further, nutrition has often been equated with availability of staple foods, ignoring the critical issues of access to food quality, dietary diversity, health, and optimal care, especially in the thousand day “window of opportunity” from pregnancy to age two when the consequences of undernutrition are the most severe and largely irreversible.

Nutrition challenges for the next 15 years

Over the last twenty years, the global burden of disease has shifted dramatically. Whereas in 1990, child underweight was the leading cause of death and disability overall, today the nutrition picture is far more complex. Child underweight remains a leading cause of death and disability among children below 5 years of age, but overweight and obesity are rising rapidly, even in the developing world2. Ending undernutrition is an unfinished agenda: 165 million children under five years of age are stunted, and while the proportion is declining in several regions, the number of stunted children is actually rising in sub-Saharan Africa. In addition, today there are 52 million children suffering from wasting, with reduced numbers in Asia but increases in Africa, yielding little improvement globally since 1990. Low birth weight, sub-optimal breastfeeding, and anemia have remained relatively stagnant, while the number of overweight children has doubled since 1990, reaching 43 million in 20103. It is now recognized that we do not live in two worlds, the wealthy suffering from overweight and the poor from undernutrition. Today, it is often the same households, families, and at times the same individuals who suffer from multiple forms of malnutrition. Exposed to poor and micronutrient-deficient diets, children stunted in early life are at heightened risk of becoming

2 Lim et al. A comparative risk assessment of burden of disease

and injury attributable to 67 risk factors and risk factor clusters in

21 regions, 1990-2010: a systematic analysis for the Global

Burden of Disease Study 201. Lancet 2012; 380: 2224-60.

3 United Nations Children’s Fund, World Health Organization,

The World Bank. UNICEF, WHO-World Bank Joint Child

Malnutrition Estimates. (UNICEF, New York; WHO, Geneva;

The World Bank, Washington, DC; 2012).

Nutrition in the Post-2015 Development Agenda EXPERT CONSULTATION | February 2013

overweight, with subsequent increased risks for numerous non-communicable diseases later in life. An implicit and ongoing challenge for nutrition is that of addressing equity so that the most vulnerable and disadvantaged populations are reached with a package of key interventions to prevent and treat malnutrition in all its forms. Lack of progress in nutrition has been, in part, a reflection of rising inequality across multiple aspects, ranging from gender to socioeconomic status to geography, religion, ethnicity, and others. Addressing the range of equity challenges in nutrition is most effectively done by incorporating nutrition objectives and goals across a range of sectors; however, this approach is often difficult and dis-incentivized given the complexity of institutional and political structures and program implementation arrangements in countries.

What do these nutrition challenges mean for the next MDGs?

Given the identified nutrition and equity challenges – and the need to sustain the improvements that have been achieved under the current MDG framework – a number of scenarios, priority nutrition indicators and targets were presented during this consultation

Scenarios and potential frameworks for nutrition in the next MDGs

Four principal options were presented: 1. Nutrition in a single goal. In this framework,

improved nutrition would be a stand-alone goal, possibly packaged with hunger as in the UN Secretary General’s Zero Hunger Challenge, with a suite of indicators and targets that would explicitly link to other sectors but that would fall under one goal.

2. Nutrition integrated across many goals. Here,

a suite of nutrition indicators would be thoughtfully integrated in multiple sectors’ goals. Key sectors that have been identified include health, water and sanitation, agriculture, education, governance, and others, and relevant nutrition indicators would be proposed for each, as appropriate.

3. Pursue the above two options in tandem; a

stand-alone nutrition goal as well as targets linked to relevant sectors.

4. Maintain nutrition as part of a single poverty

goal, similar to MDG1, changing from underweight to stunting as the indicator for measuring progress on poverty. This option was deemed insufficient.

Priority nutrition indicators for the next MDGs A wide range of anthropometric, dietary, consumption, and micronutrient indicators were presented and the pros and cons of each were discussed.

Anthropometric indicators measure nutritional status by using weight and height measures and comparing them to a global reference standard, providing information on the prevalence of children who are stunted, wasted, underweight, and overweight. Anthropometry also includes adult height and weight measurements, which are used to calculate body mass index (BMI) for the categorization of underweight, overweight, and obesity in adults. Anthropometric indicators are relatively easy to collect and are included in most population-based nutrition and health surveys and increasingly, in household consumption and expenditure surveys such as the living standards measurement surveys (LSMS).

Food consumption indicators fall into two categories: 1) measures of household food consumption, and 2) measures of individual dietary intake. These indicators are resource and time-intensive and, for that reason, are not usually included in routine data collection. Moreover, the disadvantage of household, compared to individual measures, is that they do not provide accurate intake data on each household member, a limitation when information is sought on nutrient gaps in nutritionally vulnerable women and young children. Simple dietary diversity indicators based on recall of food group intake are a potential alternative for measuring diet quality; they have been shown in cross-country studies to accurately predict micronutrient density (in breastfed

Nutrition in the Post-2015 Development Agenda EXPERT CONSULTATION | February 2013

children) and adequacy (in adult women) of the diet. One limitation of these indicators is the inability to identify a universal cut-off point that would reflect an adequate versus inadequate micronutrient intake.

Micronutrient indicators are problematic due to insufficient advances in measurement techniques. Of the four principal micronutrients measured – iron, vitamin A, iodine, and zinc – only one has a field-ready and minimally invasive application: hemoglobin testing. Hemoglobin, however, measures anemia rather than iron deficiency, and while extremely useful, it does not accurately capture progress addressing this important nutritional deficiency. There is an urgent need to develop better micronutrient measurement tools. Coverage indicators for key interventions such as vitamin A supplementation and adequately iodized salt were presented as potential alternative micronutrient indicators. Routinely gathering coverage data was felt to be important to avoid ‘backsliding’ on these two nutrition programs, which have achieved relatively high coverage (>70%) throughout the world.

Targets for nutrition indicators in the next MDGs

Targets for indicators, and whether they should be realistic or aspirational remains an important question. Aspirational targets, such as zero stunting, can galvanize high-level visibility and attention. At the same time they are difficult, if not impossible to reach, particularly by countries with the highest burden. The group favored aspirational goals that are compelling and easy to understand by lay people, paired with targets that are achievable and for which decision-makers can be held accountable. The targets endorsed by the World Health Assembly in May 2012 were deemed suitable to cover the broad scope of global nutrition challenges In the current MDGs, targets are global rather than country- or region- specific. More discussion is needed on whether the next development framework should be tailored to specific contexts, regions, and countries.

Key Messages

Reducing malnutrition will save maternal and child lives and build strong and resilient individuals, families, communities, and populations.

It is critical that nutrition receive greater focus and attention in the successor framework to the MDGs.

A single nutrition goal with a suite of indicators, building on the World Health Assembly-endorsed targets with explicit links to other sectors, is the preferred framework for galvanizing action.

A powerful alternative or tandem approach is to thoughtfully incorporate key nutrition indicators into multiple sectors’ development goals, recognizing the foundational role that nutrition plays as well as the contribution of these sectors to improved nutrition.

Childhood stunting is the priority nutrition indicator, given its power to capture inequity and chronic conditions of poor health, diet and caring practices during the crucial thousand day ‘window of opportunity’ from pregnancy to age 2.

Child overweight is also recommended for future progress tracking given its increasing prevalence and emerging contribution to death and disability around the world.

Future attention must be paid to systems and tools for gathering better data, particularly on micronutrients and diet quality, to monitor progress and drive commitment and accountability for achieving these goals.